Spotlight on Disasters: Crush Injuries

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October 6, 2015 by dailybolusoflr

On behalf of the Johns Hopkins Disaster FAST 

Submitted by: David Scordino, MD and Christina Catlett, MD

Crush injuries and other orthopedic injuries are one of the most common forms of injuries after an earthquake or other event resulting in structural collapses, such as a bomb or explosion [1, 2]
  • Crush Syndrome is associated with serious mid and long term complications (renal failure and disability) which can overwhelm an already weak health care system.
    • Crush syndrome does not require the presence of acute compartment syndrome!
    • Resultant myoglobin release and electrolyte shifts can result in hyperkalemia, acidosis, renal failure, ARDS, cardiac arrhythmias, DIC and multisystem organ failure [1]

  • Treatment
    • Focus on volume resuscitation which should begin prior to extrication from the building if possible [1, 2]
    • Potassium containing fluids should be avoided initially and thus, normal saline is a better empiric fluid than lactated ringer [1]
    • Urine output should be monitored and some experts recommend a UOP as high as 300 mL/hr, particularly in the first 24 hours [1, 2]
    • The role of sodium bicarbonate and mannitol is disputed and is most useful when severe acidosis exists or urine output is not maintained, respectively [2]
    • Dialysis may be necessary when hyperkalemia or renal failure that does not resolve with medical management [1, 2]

  • Protocol & low resource settings
    • Oral hydration without potassium can be utilized unless otherwise contraindicated
    • On the macrosystem, a dialysis referral network is essential to meet the increased dialysis needs of the population in an effective manner
References
  1. Sever MS et al.  Management of crush-related injuries after disasters N Engl J Med 2006;354:1052-1063
  2. Scharman EJ, Troutman WG. Prevention of Kidney Injury Following Rhabdomyolysis: A Systematic Review. Ann Pharmacother. Jan 2013;47(1):90-105. 

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